The present invention relates generally to surgical instruments for holding and elevating body parts and/or for maintaining a clear opening to a body area during surgery, particularly thoracic surgery. More specifically, the present invention relates to support apparatus upon which surgical devices, such as retractors and the like, may be operably mounted.
In the performance of surgery in the chest cavity, generally referred to as thoracic surgery, it is desirable to hold open the surgical cavity to allow access to the organ or body part upon which the surgery is being performed. This is especially important in the case of cardiac surgeries. An early example of a surgical retractor for use in coronary bypass surgical procedures which include dissection of the internal mammary artery is disclosed in U.S. Pat. No. 4,622,955, which is incorporated by reference.
In the device of U.S. Pat. No. 4,622,955 plural rakes which engage the body and retract the surgical cavity formed by a midsternotomy are relatively fixedly positioned with respect to each other from a rod. The rod may be elevated or lowered, as desired. However, there is no adjustment for the rakes relative to the rod, to each other or to the surgical cavity. Furthermore, the rakes are generally small, having sharply pointed tips and are generally designed to be employed in pairs for the purpose of retracting one side of a sternum which has been split by a midsternotomy. The device of U.S. Pat. No. 4,622,955 cannot provide the support required for other procedures which have been recently developed as alternatives to the midsternotomy approach to the coronary bypass, and it is not adapted for use in reoperative midsternotomy procedures.
It is well known and appreciated that in surgical procedures, time is of the essence, and delays associated with adjustments of support equipment are unwanted. Additionally, during certain procedures, it may be desirable to impose or to change a biasing force on a body portion which is undergoing a surgical procedure or treatment. Further, it is desirable to minimize the number of personnel required to assist in performance of a surgical procedure, to minimize the number of personnel who must enter the sterile field, and to minimize the tasks, such as holding a retractor, of personnel during surgical procedures. Further, it is desirable to have available to the surgeon instruments appropriately adapted to each type of procedure.
Coronary Bypass Surgery: The Midsternotomy
Coronary bypass surgery, in which the internal mammary artery is harvested from the chest wall and used for anastomosis of a vessel to bypass poorly functioning coronary arteries, has been performed thousands of times and has become an almost routine procedure for cardiac surgeons. Since the inception and throughout the development of the procedure, coronary bypass surgery has required a midsternotomy to allow access to the heart and coronary arteries. In the midsternotomy, an initial incision is made from the manubrium of the sternum to a point toward the xiphoid. Next, the sternum is split down the middle by means of a reciprocating sternal saw in order to allow access to the coronary arteries and the internal mammary artery. It has been estimated that in 1988, some 350,000 midsternotomy procedures were performed for coronary bypass surgery.
In performing the coronary bypass procedure, following the midsternotomy, it is necessary to retract one side of the split sternum in order to gain access to the thoracic cavity, and particularly to the internal mammary artery. Either the left or right internal mammary artery may be harvested for the bypass, so either side of the chest may need to be retracted. Retractors have been developed in order to provide the requisite retraction of the split sternum. An early example is disclosed in U.S. Pat. No. 4,622,955. The RULTRACT(copyright) internal mammary artery retractor is a more advanced retractor which has been developed to allow left or right internal mammary artery exposure in the undersurface of the chest wall. The RULTRACT(copyright) internal mammary retractor has been extensively used in coronary bypass surgery. The RULTRACT(copyright) retractor is not limited to coronary bypass surgery, having been used in various other thoracic surgical procedures, such as lung reduction and pericardial drainage.
The RULTRACT(copyright) internal mammary retractors include a rake plate and two or possibly three rakes. Most frequently, in use the two rakes are applied to one side of the opening formed by a midsternotomy and the rake plate is attached to a lifting device. The lifting device lifts the rake plate and the rakes, applying an upward and outward retraction to the sternum by which the surgical cavity is opened. The sternum is securely held in the open position when the lifting device is locked in position. This exposes the entire course of the mammary artery from its origin to its bifurcation, allowing its dissection. The rakes in the conventional retractor have a relatively small radius of curvature and have quite sharp tips to provide a secure attachment to the sternum. With the sternum securely held in the open position, the coronary artery dissection may then be carried out by the surgeon. In the standard midsternotomy, the retractor provides good exposure and allows the surgeon sufficient access for the dissection of the mammary artery.
After the coronary artery has been harvested, the RULTRACT(copyright) retractor is removed and a sternal retractor is placed in the chest and the grafting and anastomoses is performed. Closure is normally accomplished in this procedure by applying wires or staples to the sternum to hold it together in the properly aligned position for healing.
The midsternotomy is a highly invasive procedure, and much of the difficulty in recovering from a coronary surgical procedure involving a midsternotomy is due to the trauma resulting from the midsternotomy rather than to any trauma inflicted upon the coronary arteries or other thoracic organs and structures. As a result, a need has been identified for a less invasive procedure which will provide the surgeon with access to the coronary and internal mammary arteries with a minimum of trauma to the thoracic region.
The Mid-Cab, a Less Invasive Procedure
A less invasive procedure which has been developed to provide access to the mammary artery and the coronary arteries for coronary bypass surgery is known as the mid-cab or minimally invasive technique. In the mid-cab, an incision is made between the third and fourth rib, in the third intercostal space. The fourth rib is released from the sternum, and the incision is retracted downward by attaching a retractor rake to the fourth rib. A second retractor rake is next attached to the third rib, which is retracted upward and in the cranial direction. With access thus provided to the third rib and in the direction of the upper chest, the surgeon is able to create an opening from the third rib to the first rib or subclavian region. Via this opening, the surgeon is provided with access to the mammary artery, which is progressively dissected from the chest wall as the opening is progressively advanced toward the first rib. With the development of this procedure, a need has been identified for more advanced retractors specially adapted to the mid-cab procedure, and particularly for a retractor which can simultaneously retract the third and fourth ribs in different directions.
It is well known among cardiac surgeons that the position of the internal mammary artery in the chest is variable from patient to patient. For this reason, during the mid-cab procedure, it is sometimes necessary for the surgeon to manipulate the chest wall to provide adequate access to the mammary artery. The surgeon may have to either elevate or depress the chest wall in the region of the first rib in order to gain access to the mammary artery so that it can be dissected in this procedure. Thus, a need has been identified for devices which can assist the surgeon in the less invasive mid-cab procedure, particularly including a retractor capable of two-direction retraction at the site of the intercostal incision and devices for providing elevation and/or depression of the clavicle and first rib region of the chest wall.
Reoperative Coronary Bypass Surgery
As coronary surgery has become increasingly prevalent and postoperative coronary rehabilitation more successful, a larger number of patients are surviving longer than the expected patency of their graft conduits. This has resulted in an increasing number of patients having to undergo a second coronary bypass procedure. The second, or reoperative, procedure has sometimes been referred to as a xe2x80x9cre-doxe2x80x9d procedure. Unfortunately, the re-do midsternotomy is neither as simple nor as safe as the initial procedure. This is primarily due to the scarring and resultant adhesions which develop between the internal side of the sternum and the underlying organs and tissues of the thoracic cavity following the initial midsternotomy. When the re-do midsternotomy is performed by essentially repeating the steps of the initial procedure, an increase in morbidity and mortality has been observed. Thus, a need has arisen for an alternative procedure.
An alternative procedure which has been adapted to coronary surgery in order to avoid the dangers of the re-do midsternotomy is known as a xiphoid entry. In the xiphoid entry, an initial incision is made along the scar from the previous midsternotomy to a point midway between the xiphoid and the umbilicus. The old sternal wires are removed. The xiphoid process is excised. A single retractor rake is applied to the caudal end of the sternum and the sternum is firmly retracted in an anterior and cranial direction. This allows the surgeon to directly visualize the anterior retrosternal space, so that the retrosternal adhesions can be taken down. The surgeon progressively takes down the adhesions toward the subclavian, until the sternum is freed from the underlying organs. Once this is done, the retractor may be removed and the sternum divided with a reciprocating sternal saw as in the original procedure.
During the retraction particular care must be exercised since, first, the quite sharp rake tips of the standard retractor are applied directly to the lower end of the sternum from which the xiphoid process was excised, and second, a very strong lifting force is required to elevate the entire sternum. The possibility of unintended trauma to the sternum exists. A second problem which has been experienced with the procedure described above is that the entire retractor plate and the extra, non-used rake must be suspended in a central location in the operating field, further obstructing the work area with its already limited space available. A third problem is that due to the rake plate and various parts attaching it to the lifting apparatus, the retraction force applied to the sternum is not transmitted in a simple straight line from the lifting apparatus to the sternum. Thus, a need has been identified for a rake which is more appropriately adapted to the xiphoid entry in a re-do coronary bypass procedure.
In the procedures described in the foregoing and in additional thoracic surgical procedures, the surgeon may be required to adapt the support apparatus for retraction of the patient""s body in several directions at once. In such an instance, a single retractor held by a single support device may not be sufficient to provide the retraction required by the surgeon. Furthermore, it may be helpful to the surgeon to combine various embodiments of retraction devices in order to adequately obtain the retraction required.
As an example of a surgical application requiring a retraction device particularly adapted to the individual use, in pediatric surgery it is often necessary to introduce novel techniques due to small size of the patient. Procedures and devices designed for adult patients are frequently not useable with pediatric patients. For example, it may be necessary to adjust the angle of and direction from which retraction is applied, which in turn requires significant change in the retraction support apparatus.
Accordingly, there is a strong need in the art for surgical retractor apparatus with which to facilitate the development and implementation of new surgical procedures, particularly less invasive procedures such as the mid-cab coronary artery bypass procedure, for more radical thoracic procedures, such as a lung reduction or other procedures, and for specialized procedures, such as thoracic and other surgeries, performed upon, e.g., pediatric patients.
The present invention, in one embodiment, relates to a low profile support pole for a retractor support system which includes a splined coupling, by which both the exact angle at which the retraction device is suspended with respect to the xe2x80x9chead-to-toexe2x80x9d direction of the patient""s body, and the exact elevational angle at which the retraction device is applied with respect to the horizontal plane of the patient""s body, may be selected and reliably retained without the possibility of slippage, and while providing the maximum access to the patient and the minimum interference with the surgical team""s movements during the surgical procedure.
The splined coupling allows for adjustment of the xe2x80x9chead-to-toexe2x80x9d angle, and the low-profile support pole allows for adjustment of the horizontal angle, and both may be adjusted during the course of a surgical procedure. As a result, the surgeon may better adapt to the changing conditions and needs of the patient. The present invention is particularly useful for a partial sternotomy.
In the embodiment of the present invention mentioned in the previous paragraph, the apparatus includes a generally vertically extending support member for a surgical retraction apparatus which includes a lower portion of the support member having a rectilinear portion for insertion into an anchoring receptacle, an upper portion of the support member having a low-profile first horizontally extending portion, an extender bar with a further vertically extending portion and a second horizontally extending portion, and a splined coupling adaptor for connecting the lower portion of the support member to the upper portion having a low-profile first horizontally extending portion. The splined coupling adaptor comprises a splined segment having lock- and key-like splined portions. The splines may be involute. Preferably the key-like splined segment is disposed on the lower portion of the support member. Alternatively, the key-like splined segment may be disposed on the upper portion of the support member. In one embodiment, each splined segment comprises at least 12 teeth. In one embodiment, each splined segment comprises at least 19 teeth.
The present invention includes surgical retraction devices which may be selected and quickly implemented as required in an individual surgical procedure depending on the particular patient""s needs. These devices allow the surgeon to perform a less-invasive procedure while retaining the option to easily switch to the more radical surgical procedures, or to make other adaptations as necessary, in the event of unforeseen difficulties. When the RULTRACT(copyright) retractor system and the devices of the present invention are employed, the surgeon is provided with a greatly improved degree of adaptability in the procedures chosen during a particular surgical procedure, with a minimum change of retraction apparatus.
Thus, the present invention, in one embodiment, relates to a low profile support member for a surgical retraction apparatus, including a lower portion mountable on a support platform; an upper portion of the low profile support member having a first horizontal extension; a splined coupling adaptor for connecting the lower portion and the upper portions, wherein the adaptor comprises a splined segment having a key-like splined portion and a lock-like splined portion; and an extender portion having both a vertical extension and a second horizontal extension, the extender portion mountable on the first horizontal extension. In another embodiment, the extender portion further includes a clamp and a receptacle for receiving the first horizontal extension. In another embodiment, the receptacle is disposed such that the second horizontal extension is mounted at a right angle to the first horizontal extension. In another embodiment, the first horizontal extension is directly connected to the splined coupling adaptor with relatively minimal vertical rise therebetween. In another embodiment, the first horizontal extension is directly connected to the splined coupling adaptor substantially free of vertical rise therebetween. In another embodiment, a base portion of the low profile support member is just long enough to fit securely in and be attached to the splined coupling adapter. In another embodiment, the splined coupling adaptor enables the first horizontal extension to be securely aligned at one of a plurality of selected angles with respect to the anchoring receptacle.
The present invention, in one embodiment, relates to a method of providing surgical retraction to a patient positioned relative to a support platform, including the steps of mounting upper and lower portions of a low-profile support member with respect to each other by a lock-and-key-like splined connection and with respect to the platform, the upper portion comprising a first horizontal extension; mounting on the first horizontal extension an extender portion having both a vertical extension and a second horizontal extension; positioning a lifting device above the patient by mounting the lifting device with respect to the second horizontal extension; and applying retraction to the patient. In another embodiment, the step of mounting further comprises selecting a desired angle of orientation between the first horizontal extension and the support platform. In another embodiment, the step of mounting further comprises selecting a desired angle from which retraction is applied to the patient. In another embodiment, the step of mounting on the first horizontal extension an extender portion places the vertical extension in a position substantially aligned with a patient midline plane.
The present invention, in one embodiment, relates to a method of providing surgical retraction to a patient positioned relative to a support platform, including the steps of positioning a lifting device above the patient, said positioning comprising mounting the lifting device on a multiple part generally vertically extending low profile support member which has a lock-and-key-like splined connection between at least two of the multiple parts, the support member comprising a first horizontal extension, and mounting on the first horizontal extension an extender portion having both a vertical extension and a second horizontal extension; adjusting the position of the lifting device relative to the patient by selecting an angular relation between a first one of the parts and a second one of the parts at the lock-and-key-like splined connection; and applying retraction to the patient. In another embodiment, the step of mounting includes placing the lifting device on the second horizontal extension. In another embodiment, the step of mounting further includes selecting a desired angle of orientation between the first horizontal extension and the support platform. In another embodiment, the step of mounting further comprises selecting a desired angle at which retraction is applied to the patient. In another embodiment, the step of mounting on the first horizontal extension an extender portion places the vertical extension in a position substantially aligned with a patient midline plane.
The present invention, in one embodiment, relates to a low profile support member for a surgical retraction apparatus, including a lower portion mountable on a support platform; an upper portion of the low profile support member having a first horizontal extension; a splined coupling adaptor for connecting the lower portion and the upper portions, wherein the adaptor comprises a splined segment having a key-like splined portion and a lock-like splined portion; and an extender bar, the extender bar mountable on the first horizontal extension. In another embodiment, the low profile support member further includes a lifting device mounted on the extender bar. In another embodiment, the lifting device includes a cable which, in use, forms an acute angle between the cable and the support platform.
Using a retractor with a low profile support member in accordance with the present invention, if desired, the retraction effort can be applied at a more acute angle than with the higher profile retractor. Also, there is greater available area in the surgical field for the surgical team to move about and to operate on the patient during the surgical procedure, this being especially advantageous in the case of surgeries for relatively small size patients, such as children.
The low profile support member of the present invention, as described below, allows use of a surgical retraction device and is particularly adaptable to specialized uses such as pediatric surgery, in which it may be necessary to introduce novel techniques due to relatively small size of the patient. The low profile support member, used as described below, allows a surgeon to adapt surgical procedures and apparatus originally designed for adult patients for use with pediatric patients. For example, the low profile support member of the present invention allows the surgeon to adjust the angle of and direction from which retraction is applied. Thus, by changing the support member from a standard, relatively high support, the surgeon can adapt surgical procedures and apparatus to additional uses, such as pediatric surgery, without being forced to make significant changes in the retraction apparatus.
As additional significant benefit of the low profile support member and the methods of using it described below is the additional space in the surgical field which is made available. Because a significant portion of the vertical aspect of the low profile support member is located toward the center, away from the sides, of the surgical support platform, the surgical team is allowed more xe2x80x9celbow roomxe2x80x9d in the area in which they must stand, the sides of the surgical support platform.
To the accomplishment of the foregoing and related ends, the invention then comprises the features hereinafter fully described and particularly pointed out in the claims. The following description and the annexed drawings set forth in detail certain illustrative embodiments of the invention. These embodiments are indicative, however, of but a few of the various ways in which the principles of the invention may be employed. Other objects, advantages and novel features of the invention will become apparent from the following detailed description of the invention when considered in conjunction with the drawings.